University of SydneyWestmead

Hospital

A Global Perspective of CKD Surveillance

Endeavours

David Harris

23/08/17

(A number of slides from Adeera Levin)

CKD – achievements & gaps

Achievements Definitions & classification system Increasing awareness of CKD as public global health problemGrowing number of consortia & collaborations for basic & clinical science New therapies for some specific causes of CKDGenetic & molecular mechanisms more carefully studied & understood

Gaps in knowledgeMechanisms of disease(s); responders & non respondersEpidemiology & burden in different locationsGenetic & environmental interactions

Shortcomings described by the communityLimited possibilities to influence the course of the diseaseFailure of trials (study design, populations, size, duration…)Few mechanistic targets identifiedAbsent culture for clinical trials & inquiry

CKD increasingly recognized in multiple countries

as a public health problem

Global, regional, and national age–sex

specific all-cause and cause-specific

mortality for 240 causes of death, 1990–

2013: a systematic analysis for the Global

Burden of Disease Study 2013

Lancet 2015;385:117-171

Burden of CKD has moved from 35th

to 19th place over in less than 25y

International estimates of CKD prevalence are consistent

~ 10-16% of adults

KI S94 ;April 2005 Prevention of Renal Disease

Report from ISN 2004

James, Hemmelgarn & Tonelli, Lancet 2010

CKD prevalence 13.4% (11.7-15.1%)

Hill et al PLoS One 2016;11: e0158765

Cross-sectional study in 12 countries from six world regions: (Bangladesh, Bolivia, Bosnia & Herzegovina, China, Egypt, Georgia, India, Iran, Moldova, Mongolia, Nepal, and Nigeria)

Volunteers in screening programs & high risk clinics

CKD prevalence (N=75,058)14·3% (95% CI 14·0–14·5) in general populations

36·1% (34·7–37·6) in high-risk populations

Awareness very low: CKD 6% in general populations; 10% in high-risk populations

Awareness also low for HTN 56% and DM 69%

Lancet Glob Health 2016; 4: e307–19

Individual data pooled from 19 general-population studies from 13 European countries

KDIGO stages; CKD-Epi eGFR; ACR 30-299, 300+; age- and sex-standardized

Adjusted CKD prevalence

Stages 1-5: 3.3%(3.3%-3.3%) in Norway to 17.3% (16.5%-18.1%) in N-E Germany

Stages 3–5: 1.0% (0.7%-1.3%) in central Italy to 5.9% (5.2%-6.6%) in N-E Germany

Substantial variation in CKD prevalence independent prevalence of diabetes, hypertension,

and obesity

J Am Soc Nephrol 2015;27

CKD of unknown aetiology (CKDu)

RRT2.6m in 2010

2.3-7.1m dying without

White et al, WHO Bull 2008; Nugent et al, NCP 2011

1500

1750

1250

1000

750

500

250

00 10,000 30,000 30,000 40,000 50,000 60,000

GDP per capita (international $)

Log (all) R2=0.5963

RR

T p

reva

len

ce (

pm

p)

Low-income countriesMiddle-income countriesHigh-income countries

Liyanage et al Lancet 2015;385:1975-82

CKD – Global perspective

Common, harmful, treatable

Linked to other NCDs (DM, HTN, CVD)

Variability in approaches, resources, policiesBetween and within countries and regions

Role of health care systems in prevention and control of CKD

in integrating with national and international NCD management strategies

Need for better understanding and unified advocacy approach to CKD

ISN CKD - Closing The Gaps

All individuals with CKD who can benefit from prevention or treatment should be have access to those strategies and therapies

To improve access to identification, prevention and treatment options for all individuals with kidney disease, irrespective of geographical location

Strategic Objectives

Develop a systematic, international inventory of health systems, health status, care gaps & inequalities for kidney patients

Provide recommendations to address these gaps & inequalities, to improve standards of care

Describe essential components of CKD care

human & financial resources

health policies, structures, processes & infrastructure

Leverage lessons from country level data for regional & international dissemination

Collaborate at country level to

• provide technical assistance & advice

• stimulate & support national strategic initiatives

ISN CKD - Closing the Gaps

Global Kidney Health Atlas ( JAMA)

Global Kidney Health Summit (The Lancet)

ISN Global Policy Forums: Regional focus

Lancet Campaign ( online awareness campaign)

ISN Global Kidney Atlas

Survey of current capacity for kidney health care delivery in each country & region

6 dimensions of Universal Health Coverage (WHO)

1. Health Finance

2. Health Policy

3. Service Delivery and Safety

4. Essential Medications and Health Products

5. Health Information and Statistics

6. Health Workforce

Global, regional & national data

Biannual

N of countriesTotal population

(millions)

N of countries that completed the

survey

Population for countries that completed the

survey (millions)

Overall 202 7242 125 6734

ISN regions:

Africa 55 1160 35 964

Middle East 14 225 13 223

Latin America 24 608 16 560

North & East Asia 7 1580 6 1560

South Asia 9 1710 6 1670

OSEA 26 678 13 661

East & Central Europe

20 209 17 199

NIS Russia 11 281 6 223

Western Europe 22 429 11 318

North America 14 362 2 356

Survey of 125 UN Member States~93% of the world’s population

GKHA: global variability in availability of renal registries

for CKD, Dialysis, Tx & AKI

Healthcare services available for identification & management of CKD in

secondary/tertiary care levels by World Bank income groups

Conclusions of GKHA

Substantial inter- and intra-regional variability in kidney care across the world

Important gaps in services, facilities and workforce in many countries

Frequent kidney health workforce shortages

Poor availability of healthcare services for identifying and treating kidney disease

Underutilisation of peritoneal dialysis

Low rate of public funding for kidney care

Lack of national strategies for kidney disease

Lack of kidney disease registries

Suboptimal advocacy for kidney disease

Less than half countries have research capacity

Opportunitiesengage key governmental & non-governmental stakeholders to improve quality of kidney care

hold countries to account

devise policy implications for including CKD and AKI in the global health agenda

ISN Global Policy ForumMexico, April 2017

Co-hosted by

Mexican Health Ministry

ISN

The Lancet

International representation

Ministers of Health, PAHO,

WHO, UNESCO

Clinicians, Researchers &

Scientists

Patient groups

Goals

Improve outcomes for patients

living with kidney disease

Increase awareness of

magnitude of the problem

Increase awareness of changes

required to impact the problem

Collective commitment to change

Signed document

Mexico Policy Forum

Key messages about CKD

GLOBALLY

important contributor to NCD burden

affects up to 1 in 10 people

direct cause of 1.2 million deaths (2013)

7% of CV deaths associated with reduced kidney function (2013)

important risk multiplier of CV disease & diabetes burden

prevalence in many LMIC unknown

lack of access to diagnosis and poor awareness

therefore true global burden likely underestimated

since 1990, moved from 30th to 20th leading cause of global DALYs

LATIN AMERICA

8th most common cause of death (among top 5 in 9 countries)

10th leading cause of global DALYs (among top 3 in 3 countries)

Mexico Policy Forum

Key commitments for CKD

1. Work within current frameworks promoted by WHO & UN

Sustainable Development Goals

Universal Health Coverage

Life Course approach

2. Develop & implement public health policies to prevent & reduce risk

maternal and child health and nutrition

diabetes, hypertension, obesity and tobacco consumption

safe work environment

infectious diseases

3. Implement & support ongoing surveillance (national & regional registries)

4. Educate public and people at risk about kidney disease

5. Improve awareness of kidney disease among health care workers

6. Work towards universal health coverage

7. Support education for a skilled nephrology workforce

8. Implement early detection, prevention & treatment strategies for AKI

9. Integrate early evidence-based treatment for CKD, integrated with other NCDs

10. Implement transparent policies for equitable access to kidney disease care

11. Promote kidney transplantation

12. Support local, regional & transnational kidney research

Research

iNET CKD : International Network of CKD Cohort Studies>20 cohorts with biosamples and individual level data in CKD patientsDevelop collaborative research projects to

Identify international similarities and differences Validate findings across international boundaries …….

ISN ACTs : ISN - Advancing Clinical TrialsImprove the ability of international community to conduct important clinical trialsCollaborative capacity building:

Education and training Vetting of protocols/ harmonization

Clinical Research ProgramSmall seed grants to conduct research in LMIC Integrated with 0by25 and Closing the GapsMentoring and writing support

ISN facilitates research activities to address

some of the gaps identified

Integrated approach to improve Kidney Health

Policy & Positions

Research

OutreachAlliance Building

Mobilisation

ADVOCATE

Current ISN activities in collaboration with partners

Policy & PositionsResearch

Outreach Alliance BuildingMobilisation

ADVOCATE

*Global UHC Coalition

*World Heart Federation

*World Obesity Federation

*Global Atlas

*CKDu

*General Monitoring

* iNET, ACT, CRP

*WHO Consultations

*Kidney Health

*Obesity

*Dialysis

*Affiliated Societies

*Internal Communication

*Global Policy Forum

*Lancet Campaign

* World Kidney Day

*WHO Meetings

*External Communication

Responding to a challenging global health environment

RESOURCES &

POLITICAL WILLInformed by experts and

communities who understand the

needs

Medical advances and

innovation

Improved guidelines,

standards of care

Research and data

collection

Achieving better

global kidney health